Provider Demographics
NPI:1053379479
Name:SMITH, SHEILA M (FNP)
Entity type:Individual
Prefix:MS
First Name:SHEILA
Middle Name:M
Last Name:SMITH
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:SHEILA
Other - Middle Name:M
Other - Last Name:GOURD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:1014 N SPRINGBROOK RD STE B
Mailing Address - Street 2:
Mailing Address - City:NEWBERG
Mailing Address - State:OR
Mailing Address - Zip Code:97132-2061
Mailing Address - Country:US
Mailing Address - Phone:503-449-8988
Mailing Address - Fax:503-894-9194
Practice Address - Street 1:1014 N SPRINGBROOK RD STE B
Practice Address - Street 2:
Practice Address - City:NEWBERG
Practice Address - State:OR
Practice Address - Zip Code:97132-2061
Practice Address - Country:US
Practice Address - Phone:503-449-8988
Practice Address - Fax:503-894-9194
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2019-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201350039NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500654856Medicaid
ORR168823Medicare PIN